Provider Demographics
NPI:1366136418
Name:LIVEWELL PASSPORT OF VA LLC
Entity type:Organization
Organization Name:LIVEWELL PASSPORT OF VA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:D
Authorized Official - Last Name:FABRY
Authorized Official - Suffix:
Authorized Official - Credentials:DC FNP
Authorized Official - Phone:804-229-1554
Mailing Address - Street 1:15801 SWINDON WAY
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-5531
Mailing Address - Country:US
Mailing Address - Phone:804-229-1554
Mailing Address - Fax:844-777-1754
Practice Address - Street 1:13553 MIDLOTHIAN TPKE
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-4261
Practice Address - Country:US
Practice Address - Phone:804-229-1554
Practice Address - Fax:844-777-1754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty